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Souders D., Gepner B., Charness N., Wekezer J. 1
A USER-CENTERED LITERATURE REVIEW OF SAFETY AND HUMAN FACTORS
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ISSUES INVOLVING OLDER ADULTS AS CUTAWAY BUS PASSENGERS
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Corresponding Author:
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Dustin J. SOUDERS, MS.
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Psychology Department, 1107 West Call Street, Tallahassee, FL 32306-4301
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Phone: 850-644-6686; Fax: 850-644-7739; E-mail: souders@psy.fsu.edu
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Bronislaw GEPNER, MS.
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FAMU-FSU College of Engineering, Department of Civil and Environmental Engineering
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2525 Pottsdamer Street, Tallahassee, FL 32310-6046
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Phone (850) 410-6505; Fax: (850) 410-6662; E-mail: bgepner@fsu.edu
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Neil CHARNESS, PhD.
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Psychology Department, 1107 West Call Street, Tallahassee, FL 32306-4301
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Phone: 850-644-6686; Fax: 850-644-7739; E-mail: charness@psy.fsu.edu
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Jerry WEKEZER, PhD.
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FAMU-FSU College of Engineering, Department of Civil and Environmental Engineering
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2525 Pottsdamer Street, Tallahassee, FL 32310-6046
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Phone (850) 410-6510; Fax: (850) 410-6142; E-mail: wekezer@eng.fsu.edu
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Word count: 8,235 words text + 0 figures x 250 words = 8,235 words total
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Re-submission date: 11/04/2014
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Souders D., Gepner B., Charness N., Wekezer J. 2
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ABSTRACT
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This literature review focuses on human factors issues affecting older adults’ safe use of cutaway
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buses (i.e., a bus body carried by a van or truck chassis) that are often used as shuttles for
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assisted living facilities, in demand-response and paratransit services such as dial-a-ride, as well
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as in mainstream public transportation and shuttle systems. Because of the scarcity of data
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gathered specifically on American cutaway buses, this review uses international statistics on
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paratransit, demand-response, special transportation services (STS), and dial-a-ride services as
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substitutes, since these are the areas of public transportation that most frequently use cutaway
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buses. In the first section, we follow a user-centered approach by reviewing some the factors
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related to older adults’ driving cessation and how public transportation systems that use cutaway
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buses help make this life change easier, followed by the physiological changes that occur with
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age that decrease older adult passengers’ ability to withstand a motor vehicle crash (MVC),
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ending with those that limit older adult mobility while boarding or alighting the bus, or
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navigating the cabin. The second section consists of a review of bus crash statistics to see what
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types of injuries and outcomes are associated with older passengers in different types of MVCs.
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Finally, areas of concern and possible solutions to improve older adults’ safety when using
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cutaway buses are presented.
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Keywords: Older Adults, User-Centered Design, Cutaway Buses, Paratransit, Safety
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Souders D., Gepner B., Charness N., Wekezer J. 3
THE OLDER ADULT AS CUTAWAY BUS PASSENGER: ISSUES TO CONSIDER
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This literature review adopts a user-centered approach focused on older adults to provide
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recommendations for better design and safer use of cutaway buses in this population. It first
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covers basic data on driving cessation and alternate transportation solutions used by older adults
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that have ceased driving, such as demand-response services. Next it reviews the physiological
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problems of increased frailty and decreasing mobility that occur in old age, and that should be
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taken into consideration when designing cutaway bus interiors for older adults’ use. Emphasis is
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then shifted toward bus crash scenarios (non-collision events, collisions, and rollovers) and older
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adults’ most likely injury outcomes due to their previously discussed frailty. Human factors
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solutions and concerns are then given: first for increasing access and comfort during the use of
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cutaway buses, and second for increasing older adult safety in crash scenarios. Conclusions are
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then drawn based on the covered material. This review informs safety concerns and
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recommendations provided for cutaway bus manufacturers as well as agencies that make use of
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cutaway buses to transport elderly populations.
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Older Adults’ Driving Cessation and Post-Driving Transportation Solutions
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Approximately 40 million (13%) of the U.S. population is over the age of 65, and it is
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estimated that by 2030, 72 million (19%) of the U.S. population will be older than 65 (1). It is
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well known that our cognitive and perceptual abilities decline with age. Visual deterioration,
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decline in cognitive skills (e.g., processing speed and memory ability), and deterioration of
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motor skills with age place older drivers at greater risk of MVCs (2). In a study of European
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countries, the KSI (Killed or Significantly Injured) rate per 100 million kilometers driven for bus
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passengers was 0.4, which is considerably lower than for those that traveled in cars (3.1) as well
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as pedestrians (21.5) without taking age into account (3). Fatal Accident Reporting System
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(FARS) analyses show that fatality rates per vehicle mile traveled (VMT) or per licensed driver
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were the highest for the oldest age group, with the exception of young, inexperienced drivers (4,
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5). Older Australian drivers, particularly those over 75 years of age, were found more likely to be
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involved in a MVC that led to a serious injury per kilometer traveled than younger age groups (6,
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7). Due to these declines in their ability to safely drive, many older adults make the decision to
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stop driving themselves, or in some cases it is made for them. Having access to some form of
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transportation then becomes all the more important to their health, social inclusion, and
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maintaining their independence (8). Older adults’ decision to stop driving usually comes at a
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time in their life when they have less disposable income, and often coincides with the onset of
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neurological disease, cataracts, decreased physical activity, or functional disability (9).
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In a survey of American older adults, many faced with the decision to stop driving moved
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to retirement communities in order to take advantage of readily available transportation, of
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which, 22% reported depending on the retirement community’s bus or van for transportation
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(10). Short of transportation services provided by senior living facilities, many older adults that
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have ceased driving get around by either soliciting rides from others, or taking public
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transportation. Despite public transportation becoming more accessible globally, use of regular
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public transportation is difficult or even impossible for some individuals with disabilities (11). It
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is also worth noting that many retirement communities in the US tend to be in rural or peripheral
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areas not serviced by public transportation (12). MacKenzie (13) estimated that 10-12% of the
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British population has a mobility handicap that causes difficulty in using mainstream public
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transportation. Demand-response is defined as user-oriented public transportation services that
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Souders D., Gepner B., Charness N., Wekezer J. 4
make use of flexible routing and scheduling according to passenger needs (e.g., Special
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Transportation Services (STS) and dial-a-ride). Demand-response transportation services making
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use of paratransit vehicles (i.e., specialized transportation services for disabled passengers), often
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cutaway buses, attempt to better serve individuals with mobility impairments or older adults who
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have ceased driving. Ridership in all modes of public transportation is on the rise in all regions of
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North America, with passenger trips on demand-response services increasing from 68 million in
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1990 (before the Americans with Disabilities Act was passed in 1991), to 191 million in 2011
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(14). An American longitudinal study of older adults’ community mobility found that paratransit
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vehicles were the most commonly used mode of public transportation for those sampled (15).
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Providing Demand-Response Paratransit Services
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Demand-response is the US public transportation mode that has largest number of
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different public transportation providers, with 6,600 total in 2011 (14). A majority of these were
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non-profit providers (4,835), followed by rural providers (1,120), and then urban providers
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(645). There were slight decreases from 2010-2011 in the number of demand-response providers
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in the United States. This decrease was found to be most felt in the number of urban providers
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(9.7%), followed by rural providers (5%), while the non-profit sector showed minimal decline
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(0.2%; 14, 16). Demand response providers used 56,103 revenue vehicles out of a fleet of 68,632
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in 2012 (17). The ability and cost to provide demand-response services relies to an extent on
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location of services such as urban versus rural. In a London-based study, older adults used public
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transportation in urban settings about eight times more than in rural settings (18). Demand-
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response paratransit trips are 7-10 times more expensive per trip than fixed-route services, and
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this price efficiency gap shrinks as the area becomes less urbanized (19). Many American cities
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are paying between $14-30 for a one-way paratransit demand-response trip; that is, it costs
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between $28-60 to take one older person to and from the doctor or grocery store just once (20).
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This review contains data taken from multiple international sources, and it is important to
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know how the implementation of demand-response paratransit services differs across these
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countries. For a more in-depth review of how these services are implemented differently in
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Australia, Europe, and the United States, see Mulley et al. (21). Population density, geography,
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and government policy are factors that affect the implementation of demand-response services.
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For example, in Australia where population density is low and the federal government does not
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fund public transportation, the most successful open-access demand-response services have three
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main characteristics: 1) “Many to One” operations, 2) confined, small catchment areas, and 3)
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servicing mature residential areas. In population dense UK and mainland Europe, demand-
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response paratransit services have largely been integrated into mainstream public transportation
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with the use of low-floor buses (e.g., 22), with the severely disabled attended to by smaller, more
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specialized vehicles. In the United States, where suburbanization has led to lower population
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density, we find a much larger number of demand-response paratransit service providers than in
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Australia or Europe that service small cities and suburban areas, with fixed route services
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catering to larger metropolitan areas.
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The passenger’s age and level of disability are important to take into account in demand-
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response transportation services. Fifteen percent of those surveyed in a Swedish interview study
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aimed at assessing and improving the country’s STS were wheelchair users (23). These
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wheelchair users used STS more often than ambulatory passengers, and were also younger on
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Souders D., Gepner B., Charness N., Wekezer J. 5
average (67 for wheelchair-bound STS users vs 78 in ambulatory STS users). Telephone
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interviews with dial-a-ride users in the state of Delaware, revealed that the youngest and most
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handicapped users were the most dissatisfied of all user groups (24). The author added that the
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largest county of the three included in the survey, despite conforming to the law the most strictly,
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had the lowest user satisfaction rate, suggesting a lack of fit between the letter of the law and the
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ease and convenience expected from demand-response passengers.
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Older Adults’ Increased Frailty
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As we age, our bodies become frailer. Tolerance of bone to different loads depends on
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structure and composition, which can be affected by processes associated with disease, age, and
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hormonal influences (25). This increased skeletal fragility can be due to changes in bone material
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properties such as fracture toughness, regional changes in rib cross-sectional geometry (26, 27),
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and the calcification of the costal cartilage (28). Osteoporosis’s high prevalence, particularly in
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older women, is well established (29) and contributes to older adults’ poor injury outcomes in car
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crashes. In fact, osteoporosis and obesity were the most common comorbid factors to thoracic
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injury severity in MVCs (30). The energy required to cause an injury reduces with age (31).
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Older adults are several times more likely to sustain a life-threatening chest injury than younger
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adults when involved in relatively moderate crashes (31, 32). Foret-Bruno and colleagues (33,
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34; cited in 35) found that older adults could only withstand a chest load of 5000 Newtons while
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younger adults could withstand 8000 Newtons on average.
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Not only are older adults more susceptible to injury, they also take longer to recover from
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injuries, having more surgical, medical, and therapy workloads before being discharged from the
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hospital, significantly more complications, as well as significantly longer hospital stays (36). In a
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study looking at injury outcomes for belted drivers in road vehicle crashes in the United
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Kingdom, injury severity due to crash was shown to vary by age group, with older drivers over-
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represented in crashes in which there was a related death 30 days after the crash in both frontal
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and side-impact crashes (37).
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Older Adults’ Decreased Mobility
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Another important aspect of the aging cutaway bus passenger to keep in mind is their
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decreased mobility. The accepted definition of impaired mobility is the inability to walk a
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specified distance, such .8 km, and/or climb stairs without assistance (38, 39, 40). The
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prevalence of impaired mobility in older adults over 65 years of age is 7.7%, and goes up to 35%
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in adults older than 80 (41). Cohen et al. (42) found that only 8 of 15 older adults (older than age
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65+) without physical limitations and only 1 out of 15 that identified as having a physical
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limitation met the criteria below:
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ability to walk 360 m continuously
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manage stairs and curbs
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walk 1.2 m/s when crossing street
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It is worth noting that a significant proportion of older adults making use of paratransit buses
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might have some sort of mobility impairment. Lerner-Frankiel and colleagues (43) presented
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these benchmarks for community ambulation for older adults, which could be helpful to keep in
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mind as maximums when designing the entrance, interior, and exit of a bus, as well as when
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Souders D., Gepner B., Charness N., Wekezer J. 6
thinking of bus pick-up/drop-off locations, to better accommodate older adults with mobility
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impairments:
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The ability to walk 332 m continuously (More important when picking pick-up/drop-off
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locations)
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ability to negotiate 17.8-20.3 cm (7 to 8 inch) curb
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climb 3 steps and a ramp without a handrail
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walk at speed of 1.2 m/s when crossing street
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Older adults’ reported physical problems with using public transportation include walking to the
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stop, climbing the steps at the entrance of the bus, feeling pressure to board quickly, paying the
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fare, finding a seat, and having the bus move too soon (44). Any effort to give older adults more
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built-in assistance (e.g., handrails on steps) or more time in completing these tasks should help in
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alleviating these older adult anxieties with using public transportation. Mitchell’s 1988 report
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(45) is a useful resource that delves deeper into improving accessibility and comfort in
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mainstream public transportation for those with mobility issues.
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BUS ACCIDENTS & MOST LIKELY INJURY SCENARIOS FOR OLDER ADULTS
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General Statistics
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About 63,000 buses are involved in MVCs each year in the United States, with 14,000
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resulting in at least one non-fatal injury and 325 with at least one fatal injury (46). The rate of
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MVCs per million miles traveled for buses (3.06) is comparable to cars (3.21), even though bus
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crashes make up only 0.6% of the total number of traffic crashes in the United States. Bus and
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coach fatalities represented 0.5% of all road traffic fatalities in the European countries covered
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by the Enhanced Coach and Bus Occupant Safety-project (ECBOS), but there was a wide range
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depending on the country sampled (0.1% in the Netherlands vs 1% in Spain; 47, 3). In a national
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British bus crash survey, 14% of the 1,525 total passenger casualties occurred during collisions,
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29% during emergency action, and 57% as a result of falls and other incidents during normal
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operations (48). Forty-three percent of the non-collision casualties were over 60 years old. (44).
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A Swedish study estimated the societal costs of injuries sustained while riding STS to be about
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$23 million USD per annum, or about $14 USD per trip (49), showing that improving safety in
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STS can make an impact financially at a societal level. Next we will examine different bus crash
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scenarios to see how safety might be improved in each.
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Non-Collision Incidents
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While the injury incidence rate in STS in Sweden seems quite high at 3.2 incidents per
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100,000 trips, 86% of these injuries were maximum abbreviated injury scale (MAIS) 1 injuries
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(minor injuries such as superficial abrasions receive a score of 1, major injuries such as the
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severance of the aorta receive a score of 6), with the remaining 14% representing MAIS 2+
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injuries (50). This figure for injury incidence rate in STS provides a liberal estimate of injuries
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more severe than MAIS 1, since it includes minor injuries that would not have been reported had
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they occurred in a private vehicle, instead of a public STS vehicle. For comparison, there are 7.6
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incidents of people getting killed or seriously injured riding European buses and coaches per 100
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million passenger trips and 51.5 KSI/100 million passenger trips for European cars (47). It is
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important to keep in mind that these KSI/100 million passenger trip statistics do not take into
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Souders D., Gepner B., Charness N., Wekezer J. 7
account minor injuries, while the Swedish STS data does, leading to its inflated value when
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making a comparison between the two.
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Most injuries in STS are not due to MVCs, but rather non-collision injuries sustained by
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older, frailer passengers. More than half of the 284 injury cases included in Björnstig et al. (51)
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were due to non-collision events, 41% of which resulted in MAIS 2+ injuries. Many elderly
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adults report a fear of falling when boarding or alighting a bus, or during hard acceleration or
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braking by the driver (52, 53, 54, 55). Due to age-related increases in gait and balance problems
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(56) and decreased bone strength due to an increase in osteolysis and decrease in osteogenesis
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(57), older adults are more likely than their younger counterparts to experience lower extremity
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fractures after falls (58). Kirk et al. (52) used British MVC data to report bus passenger falls,
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and found that 64% of injuries were in non-collision accidents, with 58% of those injured being
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older than 60. Ninety-four percent of these injuries were in areas with urban speed limits
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(average speed for American demand-response vehicles while in service is 15 mph; 14), and the
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injuries were mainly caused by tripping or slipping on suboptimal floor surfaces during wet
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weather or during braking and accelerating. Such data indicate that injuries sustained in non-
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collision incidents can still be serious for passengers, especially older adults.
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Collisions
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The most common place for a bus or coach incident to take place are on low-speed, urban
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roadways (83%), but 36% of bus-related fatalities occurred on 70 mph roads (47). An analysis of
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the National Automotive Sampling System- Crashworthiness Data System (NASS-CDS) show
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that occupant age is a significant predictor of whole body MAIS even when other significant
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predictors of injury outcome are controlled for (5; 59, 60). Older adults’ skeletal structures are
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more easily damaged and the consequences of any MVC are likely to be more serious for older
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adults relative to younger adults (35, 61, 62, 63). Mean crash severity (Δv) decreases as age
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increases (30), and this higher injury rate of older adults at lower speeds shows their need for
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additional protection. It is well known that older adults carry more risk for thoracic and lower
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extremity injuries in MVCs (64, 65, 37, 66, 67). An analysis of age-related differences in AIS 3+
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crash injuries in the NASS-CDS dataset by Ridella, Rupp, and Poland (30) found that the largest
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age effect was for thoracic injury to females involved in frontal crashes. Furthermore, age was
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found to increase the risk of injury to all body regions that had sufficient sample size for frontal
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impacts, and age significantly increased risk of head and thorax injury in every crash mode.
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Ridella, Rupp, and Poland’s (30) analysis of the Crash Injury Research and Engineering Network
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(CIREN) BioTab dataset found that the most common thoracic injury type changes from soft to
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bony tissue with increasing age. Older females in this analysis also had an increased risk for head
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injuries in near-side crashes, thoracic injuries in far-side crashes and spine injuries in rollover
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crashes. The three most frequent AIS description for the two oldest age groups were:
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1. Sternum fracture (for both age groups 65-74 and > 75, but also for 45-64 age group)
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2. Greater than 3 rib fractures on one side and at least 3 on the other (both older age groups)
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3. 2-3 Rib fractures (65-74) and unilateral lung contusion with or without hemo-
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/pneumothorax (45-64 year olds and 75+)
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When it comes to lower extremity injuries, there is mixed evidence of age’s effect on injury
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severity. Multiple studies show an increased risk of head and knee-thigh-hip injury with
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advanced age (37, 68). In their analysis of the NASS-CDS from 1995-2000, Moran et al. (69)
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found that older adults were at an increased risk of lower extremity fracture during a MVC. A
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Souders D., Gepner B., Charness N., Wekezer J. 8
more recent analysis of the CIREN data set from 1997-2007 that accounted for occupant and
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crash factors (gender, BMI, stature, Δv, restraint use, occupant position, and principal direction
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of force) did not find age to be a predictor in drivers sustaining AIS 3+ femoral or tibial fractures
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in frontal collisions (70). It is important to note here that NASS/CDS has more AIS 2 injuries
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than CIREN (71). It seems that older adults may be more likely to sustain AIS 2 lower extremity
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fractures due to their increased fragility, and less likely that age plays a part in AIS 3+ lower
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extremity injuries. The older populations in these studies had lower Δv than other age groups;
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perhaps the observed difference in age’s effect on injury severity is due to the fact that older
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drivers are involved in less high-speed, and hence less violent MVCs, due to their lower driving
9
speeds in general.
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Seat belt use can improve injury outcomes in most collisions by preventing full or partial
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ejection and does not alter the amount of force sustained in crash, but rather distributes it to less
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vulnerable pelvic area, rather than the face or chest. In general there are many risk factors for
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seatbelt non-use (72, 73, 74, 75), but of particular interest to this review, younger males were
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more likely to not use seatbelts than other demographics, suggesting that older adults will most
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likely make use of a seat belt if it is available. For frontal impacts, it is important that the
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deceleration space for the passenger is adequate, to avoid the passenger injuring themselves on
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the seat back in front of them (76, 3). Though overall injury severity is mitigated with proper
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seatbelt use, seat belt syndrome (77) refers to injuries to the lumbar spine as well as intra-
19
abdominal organs due to hyperflexion over the fulcrum of the seatbelt during a MVC. Seat belt
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syndrome is most common in lap belts, but there have been cases in three-point shoulder
21
restraints as well, though they are less likely (78). Common seat belt injuries include liver and
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spleen contusions, lumbar spine fracture (Chance fracture) with frequent neurological deficits,
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and digestive tract perforations. These usually result from direct seat belt related abdominal
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compression, with distraction and hyperflexion to the dorsal spine during deceleration. The
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analyses of Kihlberg and Robinson (79) confirm that these sorts of injuries are caused by seat
26
belts, finding a higher instance of abdominal trauma in belted occupants, but it is important to
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note that other injuries were reduced. Of 651 belted occupants, 30 had abdominal injuries
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attributable to seat belts with 27 of these cases consisting of minor bruises and abrasions leaving
29
the incidence of severe trauma cases caused by seat belts at .5%, which is acceptable considering
30
the 59% drop in serious and fatal injuries seat belt usage affords (79). It is important to note that
31
during the literature search there was no documented evidence that older adults were more
32
susceptible to seat belt syndrome, but it follows logically that their frailty merits some additional
33
consideration and investigation.
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Rollover Crashes
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Rollover crashes are an area of extra concern when it comes to the safety of bus
37
passengers. French bus crash statistics collected from 1980-2005 show that in crashes in which at
38
least one bus occupant was seriously injured, frontal collision and rollover rates were almost the
39
same (45% and 42%, respectively; 80). Intrusion caused by deformation of the superstructure is
40
the main cause of fatal and serious injury during rollover, and accounts for 18% of all of the
41
injuries reported in this dataset. The trip purpose was transporting the elderly on just 4% of the
42
bus crashes in which one individual was seriously injured in this dataset. This would most likely
43
be larger in the United States due to fewer young people using buses, while more older adults
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Souders D., Gepner B., Charness N., Wekezer J. 9
rely on buses for their primary transportation. Bus passengers are at a disproportionate risk of
1
dying in rollover crashes (30.12%) than passenger car occupants (15.45%), despite their low
2
occurrence (4.57% of all fatal crashes involving buses) according to FARS data for crashes with
3
bus passenger fatalities from the years 2010-2012 (81). Bus rollover crashes, while rare, have an
4
increased probability (42%) of severe injury or passenger fatality (3), and this pattern seems to
5
be robust internationally. In data from Great Britain, rollovers were found to be the cause of 1%
6
of all casualties, while only representing 0.2% of all vehicles involved in crashes (47). In
7
Germany, Rasenack et al. (82) found that 8 of 48 total touring coach crashes analyzed were
8
rollovers, and these rollovers accounted for 50% of reported severe injuries and 90% of fatalities.
9
A seat belt’s greatest usefulness is in rollover crashes and in preventing ejection from the
10
vehicle (83). The other causes of mechanical injury during rollover can be mitigated by proper
11
seat belt usage: complete ejection (8%) and partial ejection (5%) are responsible for a significant
12
number of the observed serious/fatal injuries, while projection within the passenger compartment
13
resulted in a majority of slight injury (63%) during rollover (80). After analyzing a severe coach
14
crash in Sweden, Albertsson and Björnstig (84) found that 2-point safety belts would have
15
reduced injuries for two-thirds of all those who sustained 2-4 MAIS injuries, and that 3-point
16
belts could have possibly reduced injury 28% more. This, along with the lessened probability of
17
seat belt syndrome associated with 3-point should belts, is good evidence of why they should be
18
preferred over 2-point lap belts.
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AREAS OF CONCERN & HUMAN FACTORS SOLUTIONS FOR CUTAWAY BUS
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MANUFACTURERS
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This literature review points to some areas for improvement in optimizing cutaway bus
22
design and use for older adults. For older adults, this type of bus provides one of the safest means
23
of transportation, superior to walking or driving themselves (3, 4, 5). Maintaining mobility is
24
important in this age group, and properly designed cutaway buses can provide older adults with
25
mobility issues who have ceased driving with an accommodating, reliable, and safe
26
transportation option. The following suggestions are intended to make it easier for older adults
27
with mobility impairments to safely and comfortably use buses as an alternative to cars and are
28
split into two sections. The first discusses ways to improve older adults’ access to cutaway buses
29
and comfort while using demand-response paratransit services. The second discusses how to
30
improve their safety in crash scenarios.
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Improving Older Adult Access to Cutaway Buses and Comfort during Use
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One important initial area of intervention that does not require physically modifying the
33
bus itself involves making sure that bus drivers are properly trained in driving the cutaway bus
34
safely in urban/rural environments, operating any accessibility and/or safety equipment, as well
35
as dealing with passengers’ needs. Sulek and Lind (85) used a systems approach to create simple,
36
low-tech, low-cost fail-safe methods to increase paratransit safety and noted that paratransit
37
managers should not just rely on technological solutions to prevent service errors, since problems
38
can arise from many different elements within the service system. A large part of these methods
39
emphasized proper driver training. In a study interviewing Swedish STS drivers, when
40
discussing their vocational duties, they gave equal importance to their ability to drive in an urban
41
environment, handle the accessibility and safety equipment, and to listen and adapt to
42
individuals’ needs in real time during their ride (48).
43
Souders D., Gepner B., Charness N., Wekezer J. 10
Pagano & McKnight’s (86) review of the quality of service in paratransit from the
1
disabled user’s perspective suggests the following potential areas of improvement for vehicle
2
access and safety, which line up well with human factors’ three main outcome areas (safety,
3
efficiency, and comfort):
4
1. Making sure the aisle is wide enough to be traversed efficiently and comfortably by obese
5
passengers or passengers with walking aids (e.g., walkers, wheeled rollators, canes, etc.)
6
2. Making sure the first step is low enough for an mobility-impaired older adult to use
7
safely
8
3. Limiting the number of steps involved in boarding/alighting
9
4. Having a wheelchair lift or ramp
10
5. Providing assistance in getting from the vehicle to their destination
11
6. Lowering the probability of falling by adding handrails where necessary
12
7. Making sure the wheelchair is in a safe position within the vehicle with the proper tie
13
downs
14
One of the most common sources of anxiety and/or injury for older adults while using
15
public transportation was found to be boarding and alighting the bus. Kneeling or low-floor
16
buses could reduce the number of injuries sustained in boarding/alighting paratransit buses,
17
whose passengers are usually older and/or less physically able than most fixed route public
18
transportation passengers (55). It is important to note that low-floor buses may be at an increased
19
vulnerability to side-impact crashes. Brooks et al. (87) found that nearly 90% of older adults in
20
their sample could negotiate a 20 cm step without a handrail, and nearly the whole sample could
21
negotiate the step with use of a handrail. Schmöcker, Quddus, Noble, and Bell (88) found that
22
the mobility of wheelchair users was often better than those with walking difficulties without
23
wheelchairs (i.e., most older adults), as wheelchair users are able to make more local trips and
24
are less inhibited about using public transportation. It is important to provide room for walking
25
aids, either near the front of bus or within range of the passenger’s seat, to accommodate those
26
individuals with walking difficulties that don’t use wheelchairs.
27
Improving Older Adult Safety in Cutaway Bus Crashes
28
It seems the safety of cutaway buses would benefit from the use of 3-point shoulder belts
29
for passengers, as opposed to the 2-point belts that are more often used. Three-point seatbelts
30
were found to provide the best restraint in bus rollovers and frontal crashes (3), and were found
31
to be 16% more effective than 2-point seatbelts for drivers and 5% more effective for passengers
32
(89). A 2-point belt is sufficient to prevent passenger ejection, but could lead to passengers’
33
upper extremities and head hitting the seat back in front of them. Making the seat backs from a
34
softer material that would absorb and distribute the forces from the passenger’s head and chest
35
could help injury outcomes. Due to their overall frailty, older passengers could very well benefit
36
from using 3-point belts over 2-point belts by virtue of the 3-point belts not only keeping the
37
passenger from impacting the seat back in front of them, but also more evenly distributing the
38
crash force across the torso and avoiding the intra-abdominal injuries and Chance fractures (i.e.,
39
a flexion injury of the spine) associated with seatbelt syndrome (77). A study aimed at designing
40
effective seat belt use reminder systems conducted by Eby et al. (72) surveyed a representative
41
population on the top reasons they do not use their seatbelts when in a motor vehicle, finding that
42
44% of older adults surveyed reported lack of perceived risk as their main reason for not wearing
43
their seatbelt, followed by forgetting (22%) and convenience (e.g., belt was hard to reach; 17%).
44
Souders D., Gepner B., Charness N., Wekezer J. 11
Written reminders to make use of seatbelts, as well as conveniently placing seatbelts within the
1
often-restricted reach of older adults will likely lead to more seat belt use in this population. In
2
the case of passengers in wheelchairs, moving the upper anchor point of the shoulder belt
3
improves wheelchair occupant’s crash protection by making more contact with the occupant’s
4
shoulder and hence better coupling the occupant with the vehicle and increasing their ability to
5
successfully “ride down the crash” by decreasing their crash pulse (90).
6
7
CONCLUSIONS
8
A user-centered approach reveals a number of steps to increase older bus passengers’
9
ease of access and comfort while using cutaway buses as well as safety in crash scenarios.
10
The user’s experience begins with waiting for and boarding the bus. Decreasing the
11
distance between the bus stop and the entrance of the bus, as well as lowering the height of the
12
first step should help those with mobility issues, but without wheelchairs, safely and efficiently
13
enter the bus. The number of steps to climb when boarding/alighting should be kept to a
14
minimum, and should not exceed three steps that are close to 17.8-20.3 cm tall, the benchmark
15
provided by Lerner-Frankiel et al. (43) for recommended curb height. Handrails should always
16
be installed on both sides of any entrance steps. Inside the vehicle, handrails or grab handles
17
should always be within easy reach. Providing space to safely store passengers’ walking aids,
18
either at the front of the bus or near the passenger’s seat, should further increase both efficiency
19
and safety by increasing older passengers’ mobility inside the bus and ensuring that the walking
20
aids stay secured during crashes and other adverse events like sudden starts and stops.
21
Safety while the bus is in motion is best achieved by the use of seatbelts, and the
22
evidence presented in this review shows a safety benefit of 3-point belts over 2-point belts. This
23
more evenly distributes the potential crash forces over a wider area of the body, and could help
24
avoid intra-abdominal injuries such as those found in seatbelt syndrome. Also, in rollover
25
crashes the bus often lands on its side, and passengers wearing 2-point belts would hang from
26
their hips. It may be worth researching if the older adult hip can take this strain, and if 3-point
27
belts might help in this type of situation. Though the author found no direct evidence of more
28
frail older adults being more susceptible to seatbelt syndrome type injuries, this question, as well
29
as the cost-benefit ratio of replacing 2-point belts with 3-point belts in buses are areas that could
30
be looked into in future research.
31
32
ACKNOWLEDGMENTS
33
The authors would like to acknowledge that this paper resulted from a study funded by
34
the USDOT grant DTRT13-G-UTC42 through the Center for Accessibility and Safety for the
35
Aging Population, a Tier I university Transportation Center (UTC) at Florida State University.
36
The support is greatly appreciated.
37
38
Souders D., Gepner B., Charness N., Wekezer J. 12
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